Provider Demographics
NPI:1639284904
Name:CHAN, KIN-CHUNG (MD)
Entity Type:Individual
Prefix:
First Name:KIN-CHUNG
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES - 2ND FLOOR
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 MERCY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8368
Practice Address - Country:US
Practice Address - Phone:209-564-3700
Practice Address - Fax:209-564-3799
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA387492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A387490Medicaid
CA00A387490Medicare ID - Type Unspecified
CA00A387490Medicaid